Foundations of Continuing Education

Maintaining Competence in the Field: LearningAbout Practice, Through Practice, in Practice

GLENN REGEHR, PHD; MARIA MYLOPOULOS, PHD

Many of the assumptions about the “adult, self-directed learner” that form the basis of the current model of formalcontinuing education delivery are largely unsupported by the literature. Yet most practitioners maintain compe-tence despite the apparent flaws in this model. After elaborating a set of problematic assumptions regarding thecurrent construction of the self-regulating professional learner who uses formal continuing education to maintaincompetence, this paper explores another likely source for the learning that allows practitioners to engage in theirown continuing professional development: the process of learning from their personal experiences of solvingproblems in their daily practice.

Key Words: self-assessment, self-direction, self-regulated, learning, education, continuing, medical, professionaldevelopment

Introduction

Despite the general trend in the health professional educa-tion literature toward learner-centered language, there is stilla propensity in our field to speak about continuing educa-tion ~CE! in a way that leads naturally to a framing of learn-ing as participation in a structured delivery system, occurringoutside the context of daily practice. Perhaps not surpris-ingly, this model of CE tends to focus on content deliveryand defines CE program success by the extent to which par-ticipants have translated the content learned in the educa-tional setting into the delivery of high-quality care in thepractice setting. When this construction of continuing edu-cation as a formal, extrapractice content delivery process isinterfaced with the community’s beliefs about professionalsas self-directed, lifelong adult learners, it engenders a par-ticular construction of the self-regulating professional andthe learning activities in which she typically engages to main-tain competence. As Regehr and Eva1 have described, thisdominant construction of self-regulation as it relates to learn-

ing presumes six steps that the learning professional enactsiteratively throughout her career: ~1! through reflection ondaily practice, the self-regulating professional regularly self-assesses performance; ~2! through this self-assessment pro-cess, areas of personal knowledge or skill that seem to havedropped below professional ~or personal! standards of prac-tice are identified; ~3! recognition of this “gap” in knowl-edge or skill leads to a decision to seek opportunities toimprove in these areas; ~4! the appropriate learning oppor-tunities are engaged, such that the knowledge or skills nec-essary to perform well are learned or relearned; ~5! the newknowledge or skills are translated into action in daily prac-tice; ~6! performance is reassessed to determine whetherperformance has achieved ~at least! the minimal standardof practice in this area. A more elaborated discussion ofthis model has been richly and compellingly articulated byHandfield-Jones et al.2 Yet, as Regehr and Eva1 ~see alsoEva and Regehr3,4! have pointed out, many of the cognitivemechanisms presumed to underlie and support this self-regulatory process are questionable at best.

In this paper, we will begin by elaborating four of theseassumed mechanisms and describe some potential concernsregarding these processes that are raised by the literature:~1! that professionals naturally reflect on their performancefor the purposes of highlighting their own weakness or gaps,~2! that professionals self-assess their own weakness whenthey do try to look for them, ~3! that professionals try toredress weaknesses through learning when they do identifythem, and ~4! that professionals effectively incorporate knowl-edge acquired in educational settings into practice. We willthen suggest an alternate source of learning that, while ac-knowledged by the CE literature, has not been heavily

Disclosures: The authors report none.

Dr. Regehr: Richard and Elizabeth Currie Chair in Health Professions Ed-ucation Research; Professor, The Wilson Centre; Toronto, Ontario, Canada;Dr. Mylopoulos: Educational Researcher, SickKids Learning Institute, To-ronto, Ontario, Canada.

Correspondence: Glenn Regehr, 1E565-200 Elizabeth Street Toronto, On-tario, Canada, M5G 2C4; e-mail: g.regehr@utoronto.ca.

© 2008 The Alliance for Continuing Medical Education, the Society forAcademic Continuing Medical Education, and the Council on CME,Association for Hospital Medical Education. • Published online in WileyInterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.203

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emphasized—the process of learning in the context of dailypractice through the experiences of addressing the problemsof practice as they arise. We will describe various mecha-nisms by which this process might occur and draw a dis-tinction between what we refer to as practice drift andintentional learning. Finally we will elaborate some impli-cations of these mechanisms for the development of exper-tise and propose that the CE community might benefit froma deeper study of this process of learning about practice, inpractice, through practice.

Assumptions of the Current Model

The first assumption implicitly present in our current con-ceptualization of the self-regulating professional is the as-sumption that professionals reflect on performance data forthe purpose of exposing gaps in knowledge. Research, how-ever, has placed the strength of this assumption in doubt.Instead, studies have shown that people will often reinter-pret data that would be evidence of poor performance inways that reinforce their self-concept as competent profes-sionals. In the most simple version of this, there is strongevidence that practitioners will simply ignore or activelydiscount formal feedback that is inconsistent with their be-liefs about their own abilities5 and fail to use it as a sourceof effective performance change over time.6 However, thefield of social cognition describes a variety of much moresophisticated mechanisms by which individuals maintain astrong positive sense of self in the face of information thatwould be threatening to one’s self-concept.7 As just one ex-ample of these processes, Gilovich8 has shown that gam-blers do not ignore the negative feedback associated withgambling losses, but rather focus heavily on these losses,reinterpreting them as near-wins, thereby reinforcing theirself-concept as effective gamblers.8 Such a process is suf-ficiently pervasive among humans to be immortalized inaphorisms such as “the exception that proves the rule,” astatement that does not merely discount disconfirming evi-dence, but actually uses that disconfirming evidence tostrengthen further the original belief. Thus, it would appearthat humans generally are not as likely to search actively forpersonal weaknesses as would be implied by the dominantmodel of the self-regulating professional. If anything, weare likely to use our reflective processes to protect our self-concept as “competent despite evidence,” rather than to seekout areas of incompetence using evidence.

Second, the literature on self-assessment is not promisingregarding the assumed ability of practitioners to identify areasof weakness that might serve as domains for seeking outlearning opportunities. In evaluating the quality of self-assessment in students and practitioners alike, there are hun-dreds of research articles, many literature reviews,9–12 andone broad conclusion: the ability to self-assess areas of weak-ness is generally poor, with all but the best performers over-estimating their abilities and even the worst performersassessing themselves as above average in their performance.

Importantly, work by Kruger and Dunning13 has clarifiedthat this poor self-assessment ability is not a global trait ofsome particularly weak individuals. Rather, it is a flaw thatwe all face, particularly in our own areas of weakness, andany illusion that we as individuals are good self-assessors isbased on a set of distorting cognitive processes applied toourselves.4 Thus, it appears that it is in the areas where wemost need remediation that we are least likely to be able torecognize our weakness, casting further doubt on the modelof the self-regulating professional outlined previously.

Third, even when an area of weakness is obvious to theindividual, the assumption that the recognition of such weak-ness will lead to efforts to redress the gap is questionable.Evidence in the continuing education literature suggests thatthe identification of a particular weakness is seldom a mo-tivator for attending continuing education activities. Rather,as Miller14 has described, health professionals more oftenattend continuing education sessions that reinforce what theyalready know. This should not be particularly surprising.Learning in areas of weakness is, by definition, difficult.And if we consider learning in terms of a cost-benefit ratio,there are likely many times when the “cost” in energy thatwould be required to learn in an area of weakness is moreimmediately compelling than the perceived potential benefitof knowing more about that area. Thus, when given an op-portunity to learn, we are likely to gravitate to areas wherethe learning is easy and fun and therefore immediately re-warding: areas of strength rather than areas of weakness.Ironically, then, while adult learning principles are foundedon the premise that we engage in learning largely becausethere are perceived rewards for expending the effort, it isexactly in areas of weakness, areas where we struggle tolearn, that adult learning principles are likely to fail us as amotivator for expending the necessary effort.1 In a sense,then, the formal model of CE might be thought of as satis-fying the “needs” of clinicians by reinforcing their currentlyexisting knowledge and reinforcing their sense of compe-tence, but we might question whether this is contributingeffectively to their continuing professional development in away that maintains competence in areas where they are notcurrently strong.

Finally, even when knowledge tests suggest that a con-tinuing education event has been successful in teaching newknowledge or techniques to participants, what little evi-dence exists in the literature suggests that this new knowl-edge will seldom lead to sustained changes in practice ~cfDavis15!. As just one example, Mazmanian et al16 reportedthat of physicians attending a CE event, only 64 percentplanned a change in practice as a result of the event, andfewer than 50 percent of those who did plan a change re-ported any actual change in practice 1 to 2 months later.These results remained consistent even when anticipated bar-riers to change were addressed in the educational interven-tion. There is some literature describing the source of thisgap between knowledge gain and performance change. Forexample, Kennedy et al demonstrated that the expressed

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barriers to performance in practice are often different fromthose that truly underlie the decision not to act, such as is-sues of confidence when faced with the challenge of imple-menting the theory alone in practice.17 While such work willbe important in evolving mechanisms to help learners toovercome the gap between knowing and doing, our pointhere is to highlight the fact that the translation from knowl-edge in theory to implementation in practice is more com-plicated and less direct than might be implied by the modelof the self-regulating professional described earlier.

In short, there are many steps associated with an expliciteffort to improve practice in a particular content area throughformal continuing education. One must acknowledge thatone’s current knowledge or skills for dealing with this typeof problem are generally inadequate. One must see that thereis a new or different set of skills or approaches that are po-tentially better. One must see that the difference between thetwo is worth the effort required to learn the new way. Onemust understand exactly how to incorporate this newly learnedway into one’s local practice. And one must have the confi-dence to try when in the field alone. The literature, however,casts doubt on our ability as humans to enact these stepseffectively. Importantly, this is not just a case of a few in-dividuals who suffer from these weaknesses, and the issuesraised here cannot be dismissed as a case of “fix the prob-lematic minority if we can, but most of us are fine.” Ratherthese propensities are inherent in all of us as humans. As Evaand Regehr have pointed out previously with regard to self-assessment, this is not a “they” problem, but a “we” problem.4

Of course, our assertion that the literature casts doubt onall professionals’ capacity to enact any of these steps effec-tively is a direct challenge to those with the responsibilityto offer formal educational delivery models. Their job is toensure the continuing competence of individuals in a self-regulating profession that utilizes self-direction as a vehiclefor making explicit decisions about what is worth learning.Yet, if people cannot explicitly identify their weaknesses,then how will we help them do so effectively? If they arelikely to avoid learning in areas of weakness, how will weencourage them to engage such opportunities? And if theseare areas where learning is particularly difficult for some-one, how can we arrange the formal educational experienceto maximize the learning and the translation of that learninginto effective practice? Such are the questions that must begrappled with by those responsible for the delivery of for-mal continuing education.

Perhaps more importantly, however, these conclusions alsocreate an interesting conundrum for the field. That is, it wouldappear that the current construction of the self-regulatingprofessional is an implausible model for describing how pro-fessionals maintain competence. Yet, despite the fact thatthis is the model on which we have based our formal con-tinuing education activities in the field, we are not over-whelmed with incompetent professionals. We might ask,therefore, If our formal model of self-selected continuingeducation is not likely to be the source of maintenance of

competence in practicing health professionals, what is? Whereand how are health professionals learning, and how is thismanifesting as the continuous development of safer and moreeffective practice? To address these questions, we might dowell to look to other constructions of expertise for under-standing the relationships among practice, knowledge, andlearning. In particular, the literatures related to adaptive ex-pertise18,19 and practice-embedded knowledge20 may helpus to understand the phenomenon of learning about practicethrough practice.

Practice-Embedded Learning Opportunities

It has been argued that much of an experienced practitio-ner’s daily practice has less to do with solving problems thanwith remembering solutions. As Dreyfus and Dreyfus21 de-scribe, “When things are proceeding normally, experts don’tsolve problems and don’t make decisions: they do what nor-mally works.” In this sense, the mark of an experienced prac-titioner, according to Dreyfus and Dreyfus, might be describedas spending much of one’s practice day relatively unchal-lenged and therefore with little need ~or opportunity! for ad-ditional learning. However, as Moulton et al22 have described,what is less clear in Dreyfus and Dreyfus’s model is whathappens when things are not proceeding normally, when thesolution is not immediately apparent. Of course, the answeris that good practitioners become active problem solvers anddiscover a solution, either by search or by invention. For theindividual patient ~who just wants the practitioner to be “right”for a particular problem!, the mere identification of a goodsolution is likely sufficient. However, for the practitioner andher broader patient population, it is not. The need to discovera solution for this patient is not only an opportunity to helpthis patient, but also an opportunity to improve future prac-tice: an opportunity to learn. Sometimes this learning in-volves simply the accrual of new facts such as the dosage ofa particular drug or the Latin name for an uncommon dis-ease. At other times it might have the potential to invoke aradical shift in understanding regarding some aspect of prac-tice, a sudden understanding that colors the conceptualiza-tion of future cases and past ones alike.

Whether and how a practitioner chooses to take advan-tage of this learning opportunity may vary from person toperson and from situation to situation. There are times, forexample, that the discovery of the solution is sufficient and,once the problem is solved, the new knowledge is lost again.Each of us has examples of details that we must look up orask a colleague each time the situation arises: the telephonenumber we use regularly but still seem to need to look upevery time we need it. It would take relatively little extraeffort to “learn” the number, but we are too busy using theinformation to bother learning it. This, then, is simply prob-lem solving and should not be confused with learning. Thisis just a case of getting the job done and getting through theday. And even if the newly discovered solution is a good oneand the immediate job is done well, because the individual

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is not learning anything from the experience, engaging inthis form of pure problem solving on a daily basis has neg-ative implications for continuing professional development,for it has no impact on future practice.

There are other times when this novel solution may be-come registered in long-term memory for use when similarcases arise. Such accrual of experiences and resources overthe course of practice may often occur without much reflec-tion on why the solution might work, why this might bethe right answer, whether this is the best answer, or how theimplications of these questions might shape the way in whichone practices. Such relatively unreflective learning, there-fore, might be considered a form of incremental, often inci-dental practice improvement. It is important for practicechange and may even be the basis of developing “exper-tise” as it is often conceptualized in the medical educationliterature.23 However, this form of learning, when used ex-clusively, imposes crucial limitations on the continuing de-velopment of practice in two important ways. First, this formof practice improvement is centered on improving efficiency,rather than on acquiring a deep understanding of one’s prac-tice. As such, it might be considered a form of surface learn-ing18,24 that limits practitioners’ ability to make flexible useof the newly acquired knowledge in future practice settings.Second, because of its often unreflective nature, the result-ing changes in practice might be described as a form of prac-tice “drift” ~in the spirit described by Amalberti25! and maysometimes lead to inappropriate shortcuts and erroneous ap-proaches to practice rather than to true practice improve-ments. Despite its potential shortcomings, however, this formof incidental learning may capture the bulk of the lifelonglearning involved in a practitioner’s development toward thestage of performance described as “intuition” by Dreyfus andDreyfus21 or as the “efficiency dimension” of practice asarticulated by Schwartz et al26 and may very well accountfor the majority of practice refinement that allows the typicalpractitioner to maintain competence on a daily basis.

In the best of circumstances, there will be moments whenthe new knowledge that is created by way of practice-basedproblem solving is used not only to alter future practice, butalso to inform future practice. Under such circumstances,careful and effortful reflection on the problem, the solution,and the reasons why the solution worked can result in ex-plicit and intentional change in the conceptualization of someaspect of practice. This will likely involve the developmentof higher-order questions of practice27 leading to a recog-nition that current knowledge is inadequate28 and thereforeto searches for relevant information and the development of“new ideas.” 26 Such learning has been conceptualized asthe “innovation dimension” of practice.26 Because this typeof learning is rooted in a deep understanding of practice, itallows the practitioner to apply her knowledge flexibly andcreatively in her future practice,29 so the form of learningthat results from this process is the basis of what has beendescribed as “adaptive expertise.” 19 Of course, this form oflearning is effortful and cannot be an ongoing, unrelenting

activity, nor the only source of learning for practice im-provement. However, if practice improvement is to be any-thing other than a process of incidental accrual and drift, thisform of reflective practice-based learning is a crucial com-plement to the “efficiency dimension” of practice-based learn-ing described earlier. Thus, adaptive experts will tend towork within an “optimal adaptability corridor,” 26 balancingthe innovation and efficiency dimensions of practice im-provement. In doing so practitioners can continuously de-velop their conceptualizations of practice in an intentionaland informed way, while making effective use of their pastknowledge and experience.

Summary

Lifelong learning is the cornerstone of continuing profes-sional development. And while the delivery of formal, ex-trapractice continuing education activities should continueto be an important component in this process, the currentconstructions of the role of these formal structures are likelyinappropriate. As a result, our practitioners are likely con-tinuing to improve practice more in spite of us than becauseof us. However, they may often be doing so suboptimally,through practice drift alone rather than by way of intentionaland reflective improvements in their conceptualization ofpractice. Recognizing these possibilities, if the continuingeducation community is to have an important role in prac-titioners’ maintenance of competence, we would do well toreorient our efforts in two ways. First, by understanding andaccepting the limits of human abilities and propensities toself-identify and redress areas of weakness, we may be ableto reposition and effectively improve the value of formalcontinuing education activities. Second, by shifting our per-spective from a focus on education to a focus on learning,we will be able to direct additional efforts at understandinghow professional learning not only arises from practice, butactually occurs in practice and is informed by practice. It isour hope that by focusing research efforts on further under-standing and developing this form of learning in practice,continuing education may have a chance to become sub-

Lessons for Practice

• Many of the daily problems of practiceact as opportunities for learning; spendingtime to reflect on these moments can leadto informed and intentional changes topractice.

• Physicians may be improving ordinarily andsuboptimally through incidental accrualand practice drift.

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stantially more relevant to the continuing professional de-velopment of our practitioners.

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